Paramount Health Care
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Individual and Family Plans

  
Gender
Date of Birth
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Do you smoke cigarettes, cigars, or use any other form of tobacco/nicotine?
 
* Applicant
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Spouse
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Child
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Child
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I am applying for a Child Only Application (under 19 years old)
* Zip Code
Email Address
* I am enrolling for coverage under
Effective Date
* Coverage Length
* Required field
 
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